Cognitive-behavioural therapy in young children with obsessive compulsive disorder - Research Paper Example

?Cognitive-Behavioural Therapy in Young Children with Obsessive Compulsive Disorder: Critical Review Introduction Obsessive compulsive disorder (OCD)is one of the distressing psychological conditions that can manifest at an age as early as 4. OCD in childhood is a chronic and distressing condition. The lifetime prevalence is 2- 3 percent (Piacentini and Bergman 1181). Estimates of point prevalence indicate that at any given moment of time, 0.5-1 percent of population falling into pediatric category suffers from this condition (Freeman 337). Many children develop impairment of social, family and academic functioning. In addition to these problems, many of them have comorbid conditions like depression, anxiety and other illnesses. Infact, some studies have reported that 75- 84 percent of children suffering from OCD have comorbid disorders (Freeman 337). Traditionally, this condition was neglected, especially in children. However recent recognition of the condition has led to enhanced understanding of various treatment modalities (Piacentini and Bergman, 1181). Comorbidity with anxiety disorders and depression is common even in children and it is very important to identify these condition and also treat then, failing to do which can influence treatment and outcomes negatively (Piacentini and Bergman, 1182). The most well-tolerated treatments for OCD in children are serotonin-reuptake inhibitors SSRI and CBT (Piacentini and Bergman, 1181). Early onset OCD has some unique features which are different from adult-onset or adolescent OCD, having some implications for treatment too (Freeman et al, 71). The phenomenology is consistent across all age spans, however, traditional adult CT approaches have been modified to accommodate developmental differences which exist. In this research article, critical review of CBT in young children with OCD will be done through review of suitable literature. Critical review OCD that manifests in early childhood can be pernicious in nature and can cause severe functional impairment and derailment of normal development. Early onset OCD coincides with the beginning of formal education and difficulties related to OCD during this period can have a devastating consequence on relationships with peers and academic performance (Freeman 337). Thus, it warranted to provide early and frequent intervention to facilitate development of coping skills and also to minimize the anxiety levels of the child that many interfere with learning. There is actually not much research pertaining to treatment of OCD in this age group. Because of this, it is very important to take into account the type of treatment that is most appropriate for children who are young. According to Expert Consensus Guidelines and AACAP, the beginning treatment for all children with OCD must be either CBT alone, or a combination of CBT and SSRI drug, depending of the severity of symptoms and comorbid conditions (Freeman 338). Though SSRI drugs have good outcomes for OCD symptoms, very few drugs have been approved by FDA for use in children less than 8 years of age. Also, the rates of adverse drug reactions and variables of duration of treatment and moderators are poorly understood. For these reasons, CBT, rather than pharmacotherapy or a combination of pharmacotherapy and CBT has been treatment of choice in younger children with OCD (Freeman 338). Research pertaining to CBT in children with OCD had been done only since few years. On review of literature pertaining to CBT in children with OCD, Freeman (p.339) identified 3 major gaps with reference to CBT for OCD in young children. One is the age of participants, the next is the role of SRI in the context of CBT and the third is the use of family-based CBT for therapy. With regard to age, Freeman (p.339) opined that there are actually no studies that have specifically studied CBT for application in children less than 7 years of age. Infact most studies have focused on age groups 7- 18 years. Although, these studies are a useful starting place for research pertaining to CBT for OCD in young children, results of those research studies cannot be completely generalized to young children because of differences in the level of development that impact expression of symptoms and ability to be benefited by interventions with CBT. Due to the cognitive development levels, young children with OCD unlike older children, adolescents and adults cannot understand and identify the relationship between obsessive thought and subsequent compulsive behavior. Another important finding in the literature review by Freeman (340) is that there are very few studies which have studied CBT alone, most of the studies have used a combination of SSRI and CBT. In young children, pharmacotherapy prescription cannot be provided. Also, studies dealing with family based treatment for young children are very few and whatever are present are mainly for older children and adolescents. This is a problematic aspect for empirically informed decisions because; for young children, involvement of family is very important. Also, early onset OCD is usually familial and influenced by various family practices, avoidance behaviors and rituals. Parents of children with OCD are likely to have poor problem-solving skills, increased expression of emotions and poor confidence in the affected child. They are also likely to exhibit increased catastrophizing behavior. These aspects are very important while considering treatment of OCD in children because they are vulnerable to family influences (Freeman 342). Simpson et al (584) conducted a open trial of CBT as an adjunct to serotonin reuptake inhibitors in patients with OCD. Both children and adults were included in the study. The hypothesis in this study was that ritual and exposure prevention decreases the symptoms of OCD significantly in patients who remained symptomatic despite adequate treatment with serotonin inhibitors, thus helping them to discontinue medication. The study included patients who were taking serotonin inhibitors for atleast 12 weeks and yet remained symptomatic, which was assessed using Yale-Brown Scale score (atleast 16). The intent-to-treat group received CBT while on SSRI. The study involved 5 patients and in all the patients there were significant improvement in symptoms suggesting that ritual and exposure prevention through CBT in those not responsive to only SSRI is a useful strategy to control OCD symptoms. Promising results have been found in older children and adolescents with family based CBT. CBT models for adolescents and children with OCD mainly focus on providing skills that facilitate exposure with prevention of response or ritual. In the study by Freeman et al (p.337), a quantitative review of existing CBT approaches towards young children with OCD was done. A meta-analysis was conducted of the existing literature indicating great scope for treatment of OCD in children and adolescents with OCD. The researchers found that most of the studies pertaining to CBT were actually confounded by concomitant pharmacotherapy with SSRI, making it difficult to opine on CBT alone. The researchers also found that no controlled trial has been published within the young age group and very little research is there that has examined the young age as a moderator in CBT for OCD. The most common model that has been employed for CBT in the studies is exposure with response or ritual prevention. The theory behind this model is that persistent exposure of the patient to the feared followed by prevention of response to the situation eventually results in decrease in anxiety. Provision of CBT in the presence of SSRI medication intake results in decreased anxiety due to enhanced ability to access structures of fears, thus turning down the volume of anxiety and allowing the child to take part in exercises concerned with exposure and habituation of attendance. At the same time, when medication is given for prolonged duration, it interferes with the ability to access fear structures adequately resulting in impact on the long-term maintenance of gains of treatment. Storch et al (p.375) conducted an open trial of CBT in children with OCD who continued to have persistent symptoms despite pharmacotherapy. 5 children with inadequate symptom control with medications were given 3 weeks of intensive CBT. The symptoms were assessed at baseline and also after treatment. It was noted that there was significant clinical improvement with CBT. In yet another study by Storch et al (p. 469), relative efficacy between intensive CBT against weekly CBT was evaluated through a randomized controlled trial. The age group of children studied were 7-17 years. They received 14 sessions of weekly treatment or intensive treatment, and assessments were made at pretreatment stage, post-treatment stage and at 3 month follow up. The raters of the study were blind to randomization. The primary outcomes that were measured were Children's Yale-Brown Obsessive-Compulsive Scale, Clinical Global Impression-Severity rating, remission status and Clinical Global Improvement scale. Secondary outcomes that were measured were Children's Depression Inventory, Child Obsessive Compulsive Impact Scale-Parent Rated, Family Accommodation Scale and Multidimensional Anxiety Scale for Children. From the results of the study, it was evident that intensive CBT is an effective approach and improvement in symptoms are seen within one week of therapy initiation and the gains are maintained over a long time frame. While from the above studies it is clear that CBT is useful in the treatment of children, it is equally important to ascertain whether it is superior to pharmacotherapy or combination of CBT and pharmacotherapy. O'Kearney et al (CD004856), examined the efficacy of behavioral therapy and CBT in pediatric OCD and compared its efficacy against psychopharmacotherapy. Randomized and quasirandomized trials were taken into account. Two independent reviewers assessed the quality of selected studies. the primary outcomes that were evaluated were endpoint scores on the gold standard clinical outcome measure of symptoms and distress of OCD, interference and endpoint status of OCD. Four studies including 222 participants were included in the study for data extraction. Two of these studies showed significant improvement in functioning after treatment and reduced risk of continuing w symptoms after cessation of treatment. Pooled evidence from the studies showed that CBT with medication was better than medication alone, but not better than CBT alone, pointing towards the fact that medication therapy may not be necessary in children with OCD. The rates of drop out also were low suggesting to the point that CBT treatment is acceptable to the children and their parents. The authors opined that CBT is a promising treatment for children and adolescents with OCD and that it has better outcomes when compared to medication alone or combination of medication and CBT. The authors suggested that more trials are needed to confirm the findings evident in this study. O'Kearney (p.199) critically examined the evidence about the benefits of CBT for children and youth with OCD through review of single group studies and controlled studies. From the review it was evident that the efficacy of CBT and medication were similar and did not differ significantly. Combined treatment with medication and CBT was better than medication alone rather than CBT alone. Based on these results, the author opined that CBT must be recommended as a first line equivalent for anti-OCD pharmacotherapy and it has a potential for better outcomes. Prazeres et al (p.262) performed a systematic review of meta analysis and controlled trials to ascertain the role of CBT in the treatment of OCD in both children and adults. The model used was exposure and response prevention. In this study, it was evident that combined pharmacotherapy and CBT were superior to either single therapy alone in children. Whether manual therapy or therapy based on waiting list and whether family should be involved in therapy or whether just relaxation therapy must be provided for children is a much debated topic. Williams et al (p.449) conducted a randomized controlled trial of CBT on children and adolescents with OCD. The trial compared 10 sessions of manualized CBT with 12-week waiting list for adolescents and children. Assessors of the study were blind to treatment and the age group of patient was 9-18 years. The group who received treatment improved more than a comparison group who waited for 3 months. Based on the results of the study, it was evident that CBT is useful to treat young people with OCD and the treatment must be initiated immediately without any waiting period. Freeman et al (p.593) examined the relative efficacy of family based CBT vrs, family based relaxation therapy in children between 5-8 years of age with OCD. 42 children were recruited in the study and they were randomized to receive 12 sessions of either family based CBT or family based relaxation therapy. The main outcome measures were scoring on Children's Yale-Brown Obsessive Compulsive Scale and Clinical Global Impressions-Improvement. From the results of the study, it was evident that though there was no difference noticed in both the groups, at conventional levels, in those who completed the sessions. At conventional rates, CBT had better remission rates (50%) when compared to relaxation group (20%). In completer sample, the remission rates were 69 percent for CBT while it remained at 20 percent for relaxation therapy. based on the results of the study, the authors opined that children with early-onset OCD benefit from a treatment approach tailored to their developmental needs and family context. In a study by Whital et al (p.1559), the researchers compared CBT and exposure and response prevention or ERP delivered in a format that was individualized. This was a randomized controlled trial. While one group received CBT, the other received ERP. Both groups received treatment for 12 consecutive weeks. 59 patients completed the treatment and these were re-evaluated after 3 months time. Post-treatment, recovered status was 67 percent in those who received CBT, but it 59 percent with ERP. Also, at follow-up, recovered status was seen in 58 percent participants with ERP, but among those who received CBT, it was 76 percent. Martin and Thienemann (p.113) conducted a pilot study to evaluate the effects of group CBT in school aged children with OCD. The parents were involved in the treatment and the authors predicted improvement in the symptoms and acceptability of format. 14 children were recruited into the study and the age group was 8-14 years. The children, along with their parents received group CBT for 14 weeks. The average age of the participants was 8.7 years. 36 percent of the participants had undergone trial with medication and 36 percent had previous CBT sessions. The main outcome measures were resolution of symptoms as measured by Yale-Brown Obsessive Compulsive Scale. From the results of the study, it was evident that there was atleast 25 percent improvement in symptoms. The Mean Clinical Global Impression Impairment rating fell drastically from clinical to subclinical ratings. Even the parents reported significant improvement in symptoms. Thus group therapy with involvement of parents is necessary for treatment of OCD in young children. Conclusion OCD with onset at an young age is distressing, can be persistent, can cause impairment of the functioning and proper development of the child. Hence it is necessary to administer such therapy that facilitates complete but safe resolution of symptoms. Pharmacotherapy with SSRI, though has been found useful is not much studied in young children in terms of efficacy and safety issues. Hence, most experts prefer CBT because of lack of any side effects. This critical review aimed to study the effects of CBT in young children, but there are not many studies for this age group, hence a general study on all age groups of children was taken into account. This review projects that CBT is effective in children with OCD and is better than pharmacotherapy or even a combination therapy. Family based and group interventions are better considering the age group ad the fact that family and familial influences are likely in early onset OCD. Works Cited Page Freeman JB, Garcia AM, Fucci C, Karitani M, Miller L, Leonard HL. “Family-based treatment of early-onset obsessive-compulsive disorder.” J Child Adolesc Psychopharmacol. 2003;13 Suppl 1:S71-80. Freeman JB, Choate-Summers ML, Moore PS, Garcia AM, Sapyta JJ, Leonard HL, Franklin ME. “Cognitive behavioral treatment for young children with obsessive-compulsive disorder.” Biol Psychiatry. 2007 Feb 1;61(3):337-43. Freeman JB, Garcia AM, Coyne L, Ale C, Przeworski A, Himle M, Compton S, Leonard HL. “Early childhood OCD: preliminary findings from a family-based cognitive-behavioral approach.” J Am Acad Child Adolesc Psychiatry. 2008 May;47(5):593-602. 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Simpson HB, Gorfinkle KS, Liebowitz MR. “Cognitive-behavioral therapy as an adjunct to serotonin reuptake inhibitors in obsessive-compulsive disorder: an open trial.” J Clin Psychiatry. 1999 Sep;60(9):584-90 Whittal ML, Thordarson DS, McLean PD. “Treatment of obsessive-compulsive disorder: cognitive behavior therapy vs. exposure and response prevention.” Behav Res Ther. 2005 Dec;43(12):1559-76. Williams TI, Salkovskis PM, Forrester L, Turner S, White H, Allsopp MA. “A randomised controlled trial of cognitive behavioural treatment for obsessive compulsive disorder in children and adolescents.” Eur Child Adolesc Psychiatry. 2010 May;19(5):449-56 Read More